Isolated clival subdural haemorrhage from a dolicoectactic vertebrobasilar aneurysm: Case report and overview of endovascular treatment strategies

Posterior fossa aneurysms presenting with isolated subdural haemorrhage (SDH) have scarcely been described with no cases attributed to a vertebrobasilar (VB) location. Non-saccular VB aneurysms are a distinct sub-group and in this report we also discuss the pathophysiology and treatment options for these difficult-to-manage lesions. We present a case of a 49 year-old man who presented with a 7-day history of severe headaches who was found to have an isolated acute clival SDH. Vascular imaging revealed a VB dolicoectatic segment with superimposed fusiform dilatations that contacted the dura adjacent to the SDH. A staged treatment was performed with initial parental vessel occlusion of the ruptured vertebral artery segment and subsequent insertion of a braided stent (LEO) with flow diverting properties into the progressively dilating basilar artery. A third procedure was performed to occlude a recurrent pouch at the lower basilar dilatation. Complete angiographic occlusion was achieved and the patient is under continued surveillance. To our knowledge, this is the first case of a ruptured non-saccular VB aneurysm presenting with radiologically isolated clival SDH. Clinical history will often inform the need for vascular imaging in such atypical presentations. Managing these lesions remains an endovascular challenge and requires a specialist multi-disciplinary approach.